Correct Answer: B

Vaginismus is the painful, involuntary spasm of the musculature of the pelvis and lower third of the vagina. It may respond to properly administered dilator therapy, although there is a lack of conclusive evidence. Deepthrust dyspareunia is often the result of pelvic pathology, such as fibroids, endometriosis, ovarian cysts, pelvic adhesions, and others. Anorgasmia is usually a psychological disorder best dealt with by a psychologist or psychiatrist expert in sexual counseling and therapy. Sexual or physical abuse should be considered and the woman questioned about this possibility. Vulvar vestibulitis is an inflammatory condition of uncertain (perhaps multiple) etiology and is usually treated with topical glucocorticoids. Failure of medical therapy may require surgical excision of the affected area.

Correct Answer: D

The cycle of spermatogenesis is 73 ?5 days. This is the time required for maturation of spermatogonia to spermatozoa. The cycle is at different stages along the seminiferous tubules, necessary to ensure the presence of sperm in each ejaculate. Further, spermatozoa require approximately 3 weeks to traverse the ductal system and appear in the ejaculate. Knowing this has important implications: any therapy intended to stimulate spermatogenesis must be continued for at least the duration of one spermatogenic cycle to determine whether there is a beneficial effect. While impaired spermatogenesis may occur late in the cycle of spermatogenesis and improvement with clomiphene may occur sooner, the semen analysis should still be delayed for 90 days to provide better evidence for the presence or absence of improvement in the semen analysis. Results must be interpreted with caution because there is great biological variability in semen parameters: what is interpreted as a therapeutic effect may only be natural biological variation. Ultimately, pregnancy is the only meaningful measure of treatment success

and pregnancy may have occurred despite the therapy, not because of it.

Correct Answer: E

At term, a placental abruption severe enough to cause fetal distress warrants immediate delivery. If the pregnancy is remote from term, temporizing measures may be considered, such as observation. However, delivery should be achieved if the mother becomes hemodynamically unstable. Tocolysis is ineffective in relaxing the uterus and has the added disadvantage of causing vasodilation of an already under-filled vascular system. Amniotomy and Pitocin induction will not cause delivery rapidly enough to prevent further deterioration of the fetus. Evidence of fetal distress makes continued monitoring unacceptable.

Correct Answer: E

Organic acids produced by bacterial fermentation lower the pH of dental plaque causing demineralization and caries of the adjacent tooth. Nursing bottle caries is a pattern of caries involving the upper and lower incisors. It occurs because of prolonged contact of the tooth to a sugar-containing liquid (juice or milk). This is more likely to occur with overnight exposure or with use of a bottle. Asimilar pattern of caries may rarely occur with breast-fed babies who feed through the night. Cup feeding or drinks given during mealtimes are less likely to cause prolonged contact to the teeth.

Correct Answer: B

C. trachomatis is considered an unusual cause of otitis media at any age. N. gonorrhoeae causes conjunctivitis in the newborn. Syphilis and toxoplasmosis cause congenital infections. E. coli is one of the neonatal pathogens that also cause otitis media in neonates. The symptoms of otitis media in newborns are often similar to those of sepsis; they are subtle and nonspecific and may include poor feeding, lethargy, vomiting, or diarrhea. Once the diagnosis is established, the initial therapy should be similar to that for neonatal sepsis, such as parenteral ampicillin and cefotaxime. Under ideal circumstances, the results of cultures obtained by tympanocentesis may then allow further treatment with a more specific antibiotic of low toxicity. Older infants may respond well to oral therapy but require frequent observation.

Correct Answer: B

Infantile autism, called a pervasive developmental disorder in DSM-IV, typically is diagnosed when children do not demonstrate the acquisition of communication skills. Ability to form interpersonal relationships also is grossly impaired. Other behavioral manifestations of infantile autism include unusual repetitive mannerisms (e.g., spinning), marked anxiety during environmental changes, and high pain threshold. As to be expected, school performance is poor, though autistic children may display isolated areas (islands) of normal or superior intellectual functioning. Behavioral manipulation is useful in trying to contain the behavior of autistic children. Unlike infantile autism, childhood schizophrenia usually develops later in childhood and follows an intermittent course. Deterioration in social or school functioning is a characteristic presenting feature, along with hallucinations, delusions, and other manifestations of psychosis. Phenothiazine drugs offer effective treatment. Symptoms and signs of depression in children are similar to those in adults. However, children may not be able to recognize depressed feelings. Persistence of puzzling physical problems in association with apathetic, withdrawn behavior is a common presentation. The use of antidepressants is controversial; family and individual counseling often can be quite helpful. ADHD once was called hyperactivity and minimal brain dysfunction. Characteristic signs include impulsivity, distractibility, inattention in school, and (usually but not universally) hyperactivity. A variety of pharmacologic agents, including imipramine, dextroamphetamine, and methylphenidate (Ritalin), have been recommended for treatment of ADHD.

Correct Answer: E

Anumber of breast cancer risk factors have been identified. These include family history, benign breast disease with atypical epithelial hyperplasia, alcohol consumption, and HRT. The most common and clinically useful risk factors are age and female gender. In most patients (70%) with breast cancer, however, no other major risk factor can be identified.

Correct Answer: C

Pyloric stenosis presents with nonbilious vomiting and gastric distention. An annular pancreas does not result in obstruction, except when it is associated with an underlying duodenal abnormality. Duodenal atresia is associated with Down syndrome. It results in early onset of bilious vomiting from complete duodenal obstruction distal to the ampulla. There is a "double bubble" sign on plain abdominal radiographs from air in the stomach and proximal duodenum. Midgut volvulus is a life-threatening complication of malrotation. It presents with acute onset of bilious vomiting, usually in infants in the first year of life. There is a paucity of gas on plain radiographs, with evidence of duodenal obstruction. UGI contrast study will confirm the abnormal position of the duodenaljejunal junction and may demonstrate a corkscrew of the duodenum from volvulus. Intussusception is uncommon in newborns. Bilious vomiting is unusual at the outset, but may develop if the intussusception has been present for a significant time. Imperforate anus can be excluded by clinical examination.

If unrecognized, the infant will develop a clinical picture of a distal bowel obstruction, with dilated small and large bowel. Meckel's diverticulum can present with obstruction secondary to volvulus around a Meckel's band, with a distal small-bowel obstruction. Contrast enema will demonstrate a normal-caliber decompressed colon, with proximal dilated small bowel. Meconium ileus is associated with cystic fibrosis. Obstruction occurs from inspissated meconium in the terminal ileum. Plain radiographs may demonstrate a "soap bubble" pattern in the right lower quadrant, with a decompressed colon on contrast enema. Hirsch-sprung's disease presents with a distal bowel obstruction and delayed passage of meconium. A contrast enema may demonstrate a transition zone, with a narrow distal aganglionic segment, and proximal colonic dilatation. Jejunal atresia is a result of an intrauterine vascular accident. Infants present with bile- stained vomiting and abdominal distention early after birth. The colon is unused, and characteristically, on contrast enema, it is abnormally small in caliber

Correct Answer: B

A history of irregular menses from menarche suggests a functional disorder, such as polycystic ovary syndrome or attenuated adrenal hyperplasia attributable to an inherited enzyme deficiency. The absence of a unilateral ovarian mass on pelvic examination, the positive family history, and the early menarche favor a diagnosis of attenuated adrenal hyperplasia over that of a virilizing ovarian tumor. Women with 17hydroxylase deficiency or 11-hydroxylase deficiency are hypertensive. Women with 17- hydroxylase deficiency are also sexually infantile, not hirsute, because they are unable to produce androgens or estrogens in normal amounts. Women with 21-hydroxylase deficiency may have salt wasting and hypotension if the enzyme deficiency is sufficiently severe.

Correct Answer: B

Infants with pyloric stenosis usually present after the third week of life with symptoms of progressive pyloric outlet obstruction secondary to increasing hypertrophy of the pyloric muscle. There are often clinical signs of dehydration, but the infant usually appears well and is eager to feed. Viral gastroenteritis and urinary tract sepsis may be associated with signs of such systemic illness as lethargy, poor feeding, and, in some cases, fever. Gastroesophageal reflux more typically presents with a history of regurgitation since birth. Milk protein allergy is often associated with colicky abdominal pain and diarrhea. The pathognomonic sign on clinical examination is a palpable "olive" in the epigastrium or right upper quadrant. Abdominal ultrasound is operator dependent, but with expertise in interpretation of the study, the thickened elongated pyloric channel can be demonstrated. AUGI contrast study may show the classic "shouldering" of the pyloric muscle, with a "string sign"; this also requires expertise in performing the examination, and other causes of pyloric outlet obstruction, such as pylorospasm may be misinterpreted as a positive study. Surgical exploration should be reserved for those patients in whom the diagnosis has been confirmed and only after the infant has received fluid resuscitation. Infants with gastric outlet obstruction develop a hypochloremic, hypokalemic metabolic alkalosis. This is secondary to the loss of chloride in the gastric contents, and the renal reabsorption of sodium in exchange for potassium and hydrogen. Carbonic anhydrase converts carbonic acid to hydrogen and bicarbonate ions, allowing hydrogen to be excreted in the urine, with retention of the bicarbonate. Hence, with the metabolic alkalosis, there is a "paradoxical aciduria." Hypernatremic, hyperchloremic, hypokalemic metabolic acidosis develops in infants with diarrhea. Infants with gastroesophageal reflux do not usually develop significant electrolyte derangements. Infants with pyloric stenosis will usually require a period offluid resuscitation to correct hypovolemia as well as electrolyte and acid-base abnormalities.

This is followed by a pyloromyotomy. Infants with vomiting and diarrhea from viral gastroenteritis are often successfully managed with oral rehydration. Prokinetic agents have been used in the management of gastroesophageal reflux. Soy formulas or elemental formulas are recommended for the infant with a milk protein allergy